How Liberia quarantine may help spread Ebola

As the Ebola outbreak in West Africa continues to spread, the government of Liberia has imposed – with soldiers, barricades and some gunfire – a quarantine on one of the poorest sections of the capital city Monrovia.

And, as media like the New York Times and BBC have reported, many of the residents of the slum neighborhood, known as West Point, are none too happy about it. No surprise. How would you like it if the government came and cordoned off your neighborhood because they viewed you as a public health threat? You wouldn’t like it, at all.

“We have been unable to control the spread due to continued denials, cultural burying practices, disregard for the advice of health workers and disrespect for the warnings by the government,” Liberian President Ellen Johnson Sirleaf said in announcing the quarantine of West Point. “As a result and due to the large population concentration the disease has spread widely in Monrovia and environs.”

When the residents of the West Point slum woke up on Wednesday to find they have been cordoned off from the rest of the city, they reacted by rioting. The clashes between those in quarantine and the security forces continue.

But does it matter if the quarantined Liberians don’t like it? Turns out, it does.

Studies, like this one by the U.S. Centers for Disease Control and Prevention analyzing the global response to the 2003 SARS outbreak, have repeatedly shown that imposing large-scale involuntary quarantines have a tendency to backfire – to make the contagion worse.

As the CDC analysis of the SARS outbreak reported, Taiwanese officials discovered that their imposition of a quarantine “contributed to public panic and proved counter-productive. In virtually all jurisdictions there were some incidents of violation of quarantine. In Toronto, the two groups most likely to violate quarantine were teenagers and health care workers.”

And this was the experience with large-scale, involuntary quarantine in wealthy countries with good health care and public health systems.

During the SARS outbreak, China even decided to threaten to execute people who violated the quarantine. Killing people to stem the spread of a deadly disease seems a bit extreme, and has not been extensively studied for its effectiveness.

Quarantine is a centuries-old response to disease outbreaks. It can be highly effective, if done right. But increasingly, public health experts are discovering that the key to success in using quarantine is to get buy-in from the target community. Without some level of acceptance by those being isolated, many of those most at risk – often the poor and disenfranchised in any community – will naturally seek to avoid being identified as such. This frustrates efforts to track and treat the spread of disease, leading to wider spread.

The aid organization Médecins Sans Frontières (aka MSF or Doctors without Borders) is perhaps the most deeply involved of all the humanitarian groups still working in West Africa to treat and care for people afflicted with Ebola.  Michael Goldfarb, spokesman for MSF, said the organization does not favor quarantine as a strategy for containing the spread of the disease:

“Doctors Without Borders strongly believes that the best way to contain the epidemic is by ensuring that people understand the importance of reporting new cases in the community, and that people go to Ebola management centers,” Goldfarb wrote in an email.

“There is no indication that confining whole communities to their villages or neighborhoods is an efficient approach to containing the epidemic at such an advanced stage of the outbreak. Quarantines and curfews tend to instill fear and distrust towards the whole of an outbreak response, including health structures. Public education and thorough contact tracing should remain the top priorities for all involved in trying to contain this epidemic.”

Put another way, those who really know what it takes to fight infectious disease outbreaks emphasize that we can’t really fight infectious disease outbreaks effectively if the infected feel like it’s a war on them rather than a fight against the virus that has attacked them.

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Tom Paulson

Tom Paulson is founder and lead journalist at Humanosphere. Prior to operating this online news site, he reported on science,  medicine, health policy, aid and development for the Seattle Post-Intelligencer. Contact him at tom[at]humanosphere.org, follow him on Twitter @tompaulson and/or send a comment below.